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The Future of Medicine

Alignment - The Key To Success Of The University of Maryland Medical System

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Former CEO of the University of Maryland Medical Center, author of the books shown above, former senior investigator at the National Cancer Institute; former head of infectious diseases and director of the University of Maryland Greenabaum Cancer Center, Professor of Medicine and Public Policy at the University of Maryland, former chair Board of Governors of NIH Clinical Center, -- along with a life long love of nature and a frequent visitor to Canaan Valley in West Virginia with my wife of 53 years.

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Thursday, August 15, 2013

The
Republicans’ proposals for Medicare are quite different than the Democrats’ in
that they begin with fundamental structural changes that will convert Medicare
from a defined benefit to a defined contribution plan. The Democrat’s plan, see
my last post, approaches the fix mainly with price controls.

Politicians
realize that Medicare will not be able to continue on its current track.
Something has to change since the country will simply not be able to afford the
inexorable growth and expenditures. But politicians do not like to take away
entitlements so proposals generally are couched in vague terms and often with
positions that are unrealistic.

Congressman Paul Ryan, chair of the House Budget Committee and the
Republication Vice-Presidential nominee in 2012, presented a proposal about two
years ago embedded in the House budget proposal. It was passed in 2011 in the
House with all no votes from Democrats and died in the Senate. But then, after
negotiations with Senator Ron Wyden, a Democrat, they offered a joint
bipartisan plan, one that few other Democrats have endorsed. The essence is to
allow individuals to stay with original Medicare or select a plan from a
private insurer that offers the same benefits as Medicare. It has no effect
until 2023, i.e. only affecting those less than age 55 today. At that time, the
age of Medicare eligibility would gradually rise over ten years from age 65 to
age 67. Second, each beneficiary could choose to remain with traditional
Medicare or chose a plan from a private insurer. The government would pay a set
amount (“premium support”) towards either original Medicare or the private
plan; the individual would have to pay any overage. The amount of premium
support, according to the proposal, would be equal to the second lowest plan among
the competing insurers, including Medicare, during the first year. Individuals
of limited means would be able to purchase at discounted rates. The annual rate
of rise of premium support would be limited to the rate of rise of the GDP plus
0.5%. This means that if expenses and hence premiums rose at a greater clip,
the individual would have to shoulder the excess. In short, the Republican (or
the Wyden-Ryan) plan counts on
competition in the marketplace to drive down costs. In practice, this is very
similar to the way the Part D drug benefit works today. Thus Republicans point
to the success of Part D to bolster their claim. The Democrats fault this plan
in that if costs are not controlled, the onus falls on the enrollee, the one
most vulnerable, especially in older ages, and not the insurer nor the
government.

Since
the Republicans also state that they would repeal or largely repeal the ACA,
then the added benefits to Medicare enrollees found in the ACA such as the
annual health and wellness review and the preventive care/screening at no cost
would presumably be repealed along with the IPAB and the enhanced reimbursement
to PCPs. Presumably although silent on the issue, the Republican plan would
also be to cut physician reimbursement by the formula driven 27% (or whatever
amount is calculated in the future) of the SGR although, again, it is is very
unlikely that either Republicans or Democrats will ever allow this to happen.

The
end result of the Republican’s plan (or Ryan-Wyden bipartisan plan) would be to
cut the rate of growth of Medicare to about 3.5%, the same as the Democrats’
plan but using a much different methodology.

Two
approaches, two very different methodologies, each attempting to achieve some
slowing of the rate of rise of Medicare cost escalation. Both have pros and
cons. Some thought that after the 2012 election, the parties would come
together and develop a widely bipartisan plan endorsed by many on each side of
the aisle but that has not happened nor has there even been reasoned attempts
at bipartisan compromise – too bad because it is surely needed. Our elected
representatives should come together to find a path forward rather than bicker
and look for “points” to score against each other. That is not governing nor is
it what they were elected to do.

The
next post will describe how Medicare could improve primary care quality and
reduce costs beginning immediately.

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Praise for Dr Schimpff

The craft of science writing requires skills that are arguably the most underestimated and misunderstood in the media world. Dumbing down all too often gets mistaken for clarity. Showmanship frequently masks a poor presentation of scientific issues. Factoids are paraded in lieu of ideas. Answers are marketed at the expense of searching questions. By contrast, Steve Schimpff provides a fine combination of enlightenment and reading satisfaction. As a medical scientist he brings his readers encyclopedic knowledge of his subject. As a teacher and as a medical ambassador to other disciplines he's learned how to explain medical breakthroughs without unnecessary jargon. As an advisor to policymakers he's acquired the knack of cutting directly to the practical effects, showing how advances in medical science affect the big lifestyle and economic questions that concern us all. But Schimpff's greatest strength as a writer is that he's a physician through and through, caring above all for the person. His engaging conversational style, insights and fascinating treasury of cutting-edge information leave both lay readers and medical professionals turning his pages. In his hands the impact of new medical technologies and discoveries becomes an engrossing story about what lies ahead for us in the 21st century: as healthy people, as patients of all ages, as children, as parents, as taxpayers, as both consumers and providers of health services. There can be few greater stories than the adventure of what awaits our minds, bodies, budgets, lifespans and societies as new technologies change our world. Schimpff tells it with passion, vision, sweep, intelligence and an urgency that none of us can ignore.

-- N.J. Slabbert, science writer, co-author of Innovation, The Key to Prosperity: Technology & America's Role in the 21st Century Global Economy (with Aris Melissaratos, director of technology enterprise at the John Hopkins University).